Patient Controlled Analgesia

PatientControlled
Analgesia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Patient-controlled analgesia is a
programmable delivery system by
which patients self-administer
predetermined doses of analgesic
medication at the push of a button

Patient-controlled analgesia (PCA) has

become a standard technique in the
clinical treatment of pain, allowing
patients to self-administer
predetermined doses of analgesic
medication


PCA systems also record patient usage

information such as total number of
demands and drug delivery during the
previous 1- and 24-hr periods

Current PCA models usually contain :

Initial loading dose
Demand (bolus) dose
Lockout interval
Basal continuous infusions
1- to 4-hr maximal dose limits

Demand dose
The demand dose is the amount of
analgesic the patient receives after
activation of the pump

Demand dose
Optimization of efficacy and safety
depends on the selection of a demand
dose large enough to provide sufficient
analgesia but small enough to
minimize side effects

Lockout interval
The lockout interval is the amount of
time following a successfully delivered
demand dose
during which the patient can
administer no further opioid even if the
system is activated

Lockout interval
Theoretically, use of a lockout interval
that is less than the time to peak effect
of the drug may result in inadvertent
overdosage due to stacking of analgesic
doses
However, lockout intervals between 5
and 10 min appear optimal regardless
of the opioid used
Continuous (Basal) Infusion

A continuous infusion delivers a set
amount of opioid every hour without
the need for the patient to activate the
system


Continuous infusions are not
recommended in: Opioid-nave
High-risk patient populations such as
the elderly
Use of other sedatives
Obstructive sleep apnea
Morbid obesity

May be needed in opioid-tolerant
patients
One way to achieve this is to
determine an intravenous equivalent
for the amount of opioid the patient
takes in a day and divide this amount
by 24 h and administer this as the
hourly continuous infusion rate
Hourly Limit
An hourly limit sets the maximum
amount of opioid that can be
administered in the given
time period
An hourly limit is automatically
determined
by the setting of a demand dose and
lockout interval
Rescue (Loading) Dose

Rescue doses are a specific amount of
opioid delivered by a health-care
provider that is generally in excess of
the patients demand dose given when
the level of analgesia from the PCA
is inadequate


Li-4 or Hegu point

ADVANTAGES OF PCA

Patients like the security of knowing :

They can achieve pain relief quickly
and easily without involving a nurse
Not having to wait for pain relief
Not having intramuscular (IM) or
subcutaneous injections

The ability of patients to titrate

analgesics to their needs can
theoretically generate a steady plasma
level of analgesia and avoid the peaks
and troughs associated with bolus
dosing on a 3- to 4-hr basis

PCA may avoid subtherapeutic opioid

concentration troughs, which can be
associated with unpleasant recovery
secondary to guarding, poor chest
expansion, and reluctance to mobilize

PCA may also help avoid excessive

peak plasma concentrations, with
associated respiratory depression and
sedation

Two meta-analyses demonstrated that

PCA was
associated with higher patient
satisfaction and greater analgesic
efficacy (compared with IM opioids),
there was no difference in adverse
effects

Recent comparisons of PCA with

conventional methods of opioid
analgesia have produced contradictory
results. Some show significantly
better analgesia with PCA and others
report no difference

Recent studies also report similar

incidences of nausea and vomiting,
sedation, pruritus, and
bowel function, suggesting that the
differences in total opioid dosages
between PCA and conventional
approaches may be relatively
unimportant
Increasing plasma concentrations of

opioid usually cause sedation prior to
causing clinically
significant respiratory depression
Sedation usually impairs the ability of
the patient to activate the PCA

Not every patient is a good candidate

for PCA:
patients must be cooperative
must comprehend the concept
must be able to push the PCA button

PCA may not be appropriate:

for very young children
for patients with certain mental or
physical limitations

Nurse-controlled analgesia (NCA)

May be used if the patients age,
developmental level, or muscle
strength interact with the ability to use
the PCA device

DISADVANTAGES OF PCA

The most frequent negative

perceptions relate to
Inadequate analgesia
Presence of side effects

Some patients also report

Not trusting the PCA pump
Fearing overdose or addiction

Oversedation with PCA can occur :

Repeated excessive use (patient
misunderstanding of the analgesic
goal)
Mistaking the PCA handset for the
nurse call button
Family, visitor, or unauthorized nurseactivated demand boluses
Operator errors can cause

oversedation:
programming of incorrect bolus dose
size
Incorrect concentrations
Incorrect background infusions
Unintended background infusions
Standardization of protocols and drug

concentrations within an institution
may reduce the chance of program
errors

Mechanical malfunctions of a PCA

pump can occur, with inadvertent
excessive medication delivery

IMPORTANCE OF
ACUTE PAIN SERVICE

An acute pain service (APS), which

often
consists of a team of physicians and
nurses that are well educated about
PCA, may also promote PCA safety and
efficacy

Comparison of PCA managed by an APS

versus
PCA managed by the surgical staff
indicated that patients with APSsupervised PCA had significantly fewer
side effects, used more opioid, were
more likely to have adjustments made
to the PCA dose in response to
inadequate analgesia or side effects
TYPES OF PCAs

INTRAVENOUS PCAs
NONINTRAVENOUS PCAs
Patient-controlled epidural analgesia
Peripheral nerve catheter patient-controlled analgesia
Subcutaneous PCA (SC PCA)
Intranasal PCA (PCINA)
Transdermal PCA


Nei Ting

INTRAVENOUS PCAs

Opioids that are pure -receptor agonists

tend to be the first choice (in opioids) for
IV PCA
The ideal opioid for IV PCA would have
A rapid onset of action
High efficacy
Intermediate duration of action
Without significant accumulation of drug
or metabolites over time

Morphine
hydromorphone
fentanyl
most closely fulfill

criteria and are
widely used for
opioid-based IV PCA

Meperidine metabolites can

accumulate, suggesting that
meperidine may not be a good first
choice for IV PCA


For safety reasons, a continuous

background infusion with IV PCA
should only rarely be prescribed for
spontaneously breathing opioid-nave
patients

Continuous infusions pose increased

risk for respiratory depression
If a patient becomes sedated,
continuing delivery of opioid at a basal
rate may cause respiratory depression

Continuous opioid infusion in

association with PCA may provide a
more constant plasma opioid levels
and improve analgesia ??

However, other investigators found

that addition of a basal infusion rate
did not reduce pain, fatigue, or anxiety
and also failed to improve patients
quality of sleep

Most PCA programming errors that

have resulted in adverse side effects
occurred during the use of basal
infusions

In selected opioid-tolerant patients

with
high opioid requirements, a
background infusion may be used to
deliver the equivalent of the usual
opioid dose taken by the patient

ketamine
Addition of ketamine [NMDA] to IV PCA
solutions may improve analgesia in
some, but not all, circumstances
NMDA receptors are associated with the
early development of opioid tolerance
ketamine can arouse psychomimetic
effects and impair cognition

Naloxone
Ultralow doses of naloxone (0.6 g added
to 1 mg PCA morphine) led to a lower
incidence of nausea (not vomiting) and
pruritus,
with no change in pain relief or morphine
use
But a 10-fold increase in dose (6 g added to
1 mg PCA morphine) resulted in increased
pain and higher morphine requirements
Clonidine
Clonidine is an a2-adrenergic agonist
with analgesic properties
Addition of clonidine to morphine PCA
significantly reduced nausea and
vomiting in a female population
undergoing lower abdominal surgery?
But in other studies was not proven





Patient-controlled
epidural analgesia
(PCEA)

In many situations, epidural analgesia

is superior to IV PCA:
A meta-analysis demonstrated that for
all forms of epidural analgesia
including PCEA provided superior
postoperative analgesia compared

with IV PCA
In addition to providing better pain control,

epidural analgesia also has the potential
benefits:
Decreased morbidity such as
Fewer cardiopulmonary complications
Less thromboembolism
Better mental status
Earlier restoration of gastrointestinal
function
Enhanced functional exercise capacity
Earlier discharge from the hospital
Potential risks associated with the

placement of a catheter
Epidural hematoma
Infection
Neurologic injury
In particular, thromboprophylaxis with
potent anticoagulants may limit use of
PCEA

Epidural analgesia with a local

anesthetic combined with an opioid
provides better
postoperative analgesia than epidural
or systemic opioids alone, and may
improve postoperative outcome


In contrast to IV PCA, a continuous

background infusion is routinely used
for PCEA
Background infusion can maintain a
continuous segmental sensory neural
blockade, but may increase the
incidence of complications such as
hypotension and motor blockade

Addition of clonidine (2 g/ml) to

ropivacaine-fentanyl PCEA after total
knee arthroplasty reduced the need for
opioid rescue without jeopardizing
hemodynamics



PCEA with clonidine plus local

anesthetic can provide adequate
analgesia in some circumstances,
without the usual opioid-related side
effects such as nausea or pruritus


Peripheral nerve catheter

patient-controlled
analgesia

Nerve block techniques are

increasingly popular for management
of postoperative pain particularly with
orthopedic surgery


Common nerve blocks, including

Brachial plexus
Sciatic
Femoral nerve blocks
.

PNC PCA
Infections and neurologic
complications, although rare, are
possible
In contrast with neuraxial blocks,
there is less
concern about interaction of
anticoagulants
and peripheral nerve blocks.
Common concentrations of local

anesthetic
for PNC PCA include
Ropivacaine, 0.2% to 0.3%,
Bupivacaine, 0.12% to 0.25%

In PNC PCA
Opioids may increase side effects
without improving analgesia
Addition of clonidine to ropivacaine for
PNC PCA
does not improve analgesia

In PNC PCA
A low-dose continuous infusion
(combined
with a demand dose) reduces local
anesthetic consumption without
compromising analgesia, in
comparison with continuous infusion
alone

Subcutaneous PCA
Data on the effectiveness of SC PCA
compared with IV PCA are inconsistent

Intranasal PCA
The opioid most commonly studied for
use in PCINA is fentanyl
The bioavailability of fentanyl via the
intranasal route is 0.7
Therefore a PCINA bolus dose of 25 g
is equivalent to an IV PCA bolus dose
of 17.5 g

Transdermal PCA
An iontophoretic transdermal PCA
fentanyl system (Ionsys) is now
available
It uses a low intensity electric current
to drive the drug from the reservoir
through the skin and into the systemic
circulation


The Ionsys PCA system, which delivers

a 40-g-bolus dose over 10 minutes,
has been shown to be more effective
than placebo for pain relief after major
surgery


SPECIAL
CONDITIONS

LABOR PAIN

The most common modality for pain

control in labor is epidural analgesia

IV PCA and PCEA has the same rates of

cesarean delivery or instrumental
vaginal delivery

However, patients receiving IV PCA

were more
likely to receive antiemetic therapy,
had more sedation, and more
neonates in this group required
naloxone and active resuscitation (52%
vs. 31%)

Patients receiving PCEA had better

pain relief and greater satisfaction with
their analgesia
Choice of epidural infusion mixture as

well as PCEA regimen is still under
debate

Addition of a basal rate to PCEA may

further improve labor analgesia
Demand-only PCEA was associated with
higher incidence:
breakthrough pain, higher pain scores,
shorter duration of effective analgesia,
and lower maternal satisfaction,
compared
to PCEA with background infusion

Some parturients do not want epidural

analgesia or have clinical conditions
that contraindicate its use
In this situation IV PCA should be
considered

Administration of opioids to parturients

can cause the newborn infant to be
sedated or have impaired respiration

Some practitioners limit exposure of

the fetus to opioids by discontinuing IV
PCA once the mothers cervix is dilated

IV PCA (compared to intermittent IM

dosing)
may provide better pain relief and
reduce maternal sedation, respiratory
depression, and nausea

Compared to IM dosing, IV PCA for

labor analgesia reduces umbilical cord
blood opioid levels

Use of shorter-acting opioids for labor

IV PCA (such as fentanyl, alfentanil,
and remifentanil)
has been advocated in the hopes of
reducing neonatal respiratory
depression


PAIN CONTROL
IN
PEDIATRIC
PATIENTS
The critical determinant of

successful PCA implementation in
the pediatric population is the
ability of the patient to understand
the basic principles of PCA use

As a result, children younger than 4

years of age are not good candidates
for PCA use

Children aged 4 to 6 years can use

PCA pumps with the encouragement of
nursing staff and parents
Nonetheless, the success rate in this
age-group is low

Children older than 7 years of age

often can use PCA independently

Parent-controlled analgesia, however,

bypasses the basic safety system of
PCA and has
been discouraged in the postoperative
setting

Basal opioid infusions have also been

successfully used by some physicians
in the pediatric population for
postoperative analgesia
However, some studies have shown an
increased risk of hypoxemia in children
receiving basal narcotic infusion with
PCA



PAIN CONTROL IN
CANCER PATIENTS

The dosages of narcotics used in

treating cancer pain often surpass
those used postoperatively

Utilization of basal continuous opioid

infusions for the management of
cancer pain is very valuable and, in
contrast to postoperative pain
management, should be encouraged

The use of methadone in PCA pumps, a

practice
uncommonly advocated for
postoperative pain, is also a useful
consideration in treating intractable
cancer pain

PCA Monitoring

There are recommendations from the

Anesthesia Patient Safety Foundation
(APSF):
Use of continuous monitoring of
oxygenation (i.e., pulse oximetry) and
ventilation in patients receiving PCA

Especially when supplemental oxygen

is used, monitoring of ventilation
should be undertaken with a
technology designed to assess
breathing or estimate arterial carbon
dioxide concentrations

GemStar Medication

CADD-Prizm

Third-generation Hospira PCA

device

Curlin Medical 4000

Alaris System

Pain Care 3200

The On-Q Painbuster pump

The Stryker Pain Pump



Patient Controlled Analgesia

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PatientControlled

Dr Mehran Rezvani pain fellowship